early initiation of extracorporeal life support in refractory ohca

Conditions: Cardiac Arrest; Out-Of-Hospital Cardiac Arrest; Sudden Cardiac Death

Summary: despite adequate conventional cardiopulmonary resuscitation (ccpr) and attempted defibrillation, a considerable number of patients in cardiac arrest fail to achieve sustained return of spontaneous circulation. the inception trial is a multicenter, randomized controlled trial that will explore extracorporeal cardiopulmonary resuscitation (ecpr) in patients in refractory out-of-hospital cardiac arrest (ohca) presenting with ventricular fibrillation or tachycardia. it aims to determine the effect on survival and neurological outcome. additionally, it will evaluate the feasibility and cost-effectiveness of ecpr.

there are approximately 275,000 cases of out-of-hospital cardiac arrest (ohca) per year in europe, of which two-thirds have a primary cardiac origin. however, despite adequate conventional cardiopulmonary resuscitation (ccpr) and attempted defibrillation, a considerable number of these patients fail to achieve sustained return of spontaneous circulation (rosc). treatment of the underlying cause of the arrest, in most cases coronary artery occlusion, is paramount. but in the absence of rosc, the possibilities to perform these life-saving interventions are limited. continued ccpr is currently the standard of care for these patients. initiation of extracorporeal cardiopulmonary resuscitation (ecpr) restores circulation, with the potential to minimize (or even reversing) organ damage, prevent re-arrest due to ischemia-triggered myocardial dysfunction and providing a bridge to possible diagnosis and treatment. several studies have demonstrated that ecpr is feasible and may be advantageous with respect to survival and neurological outcome. the inception trial aims to compare ecpr to ccpr in the population that is expected to benefit the most from this intervention: young patients presenting with ventricular fibrillation or tachycardia (vf/vt) and a refractory cardiac arrest. furthermore, it will provide data on the cost-effectiveness of this intervention, which to date has been unavailable. although the costs may prove to be high, the gain in quality-adjusted life years (qaly's) may be substantial given the fact that most patients are relatively young and the current alternative carries a poor prognosis. this can determine whether ecpr should be pursued as a standard of care in patients with refractory arrest.

Eligibility criteria:
inclusion criteria: 1. ≥18 - ≤70 years 2. witnessed ohca (by bystanders) 3. initial rhythm of vf/vt or aed administered 4. bystander bls exclusion criteria: 1. rosc within 15 minutes of conventional cpr with sustained hemodynamic recovery 2. terminal heart failure (nyha iii or iv) 3. severe pulmonary disease (copd giii of giv) 4. disseminated oncological disease 5. obvious or suspected pregnancy 6. bilateral femoral bypass surgery 7. known contraindications for ecpr 8. known pre-arrest cpc-score of 3 or 4 9. known limitations in therapy or a do not resuscitate-order 10. multitrauma (injury severity score \>15) 11. expected time-to-start cannulation \> 60 minutes

Keywords: ecpr extracorporeal cardiopulmonary resuscitation ohca out-of-hospital cardiac arrest cpr cardiopulmonary resuscitation ecmo extracorporeal membrane oxygenation refractory cardiac arrest